final - ortho Flashcards

Question

femoral anteversion/tibial torsion (intoeing)

Answer 1

-Intoeing is usually due to either femoral anteversion or tibial torsion -Femoral anteversion: Internal rotation of the knees, compared to hips -Tibial torsion: Rotation of leg between knee and ankle -No gait/ambulatory issues, but may cause tripping during running activities -Typically, more noticeable later in day due to weakness of the hip external rotator musculature (used to compensate for intoeing throughout the day) -Both largely self-limiting -Tibial torsion remodeling up to 8-10 years in females, 10-12 years in males -Femoral anteversion remodeling another 2-4 years past tibial torsion remodeling -Tx: -Education/reassurance -No work-up unless persistence past 8-10 years of age and/or causing functional ambulatory issues -Physical therapy -Surgical treatment for true bone rotational deformity (if symptomatic)

Answer 2

-Genu varum (bowleg) is normal from infancy through 3 years of age > then alignment changes to genu valgum (knock-knee) until ~ 8 years of age > adult alignment (5-9 degrees of anatomic valgus) -Orthopedic referral if: -Bowing persists past 2 years of age, increases rather than decreases, occurs only in 1 leg -Knock-kneed in association with short stature -Pathological genu varum is usually secondary to tibial rotation (Blount disease) -Pathological genu valgum is usually caused by skeletal dysplasia or rickets -Tx: -Individuals with genu varum may be at future risk for OA – bracing may be appropriate -Osteotomy for severe problems

Answer 3

-1-2/1,000 live births -3 features required for dx: -Plantar flexion of foot at the ankle joint (equinus) -Inversion deformity of the heel (varus) -Medial deviation of the forefoot (adductus) -3 categories: Idiopathic (hereditary component), neurogenic, and those associated with syndromes -Treatment -Manipulation of foot to stretch contracted tissues on medial/posterior aspects followed by casting (Ponseti technique) -Serial castings performed on a weekly basis x 6-8 weeks -If remaining equinus following casting > surgery (Achilles tenotomy) -After full correction: Night brace for long-term maintenance

Answer 4

-Congenital foot deformity, characterized by inward deviation of the forefoot -MC foot abnormality (1-2/1,000 live births) -Rigid versus flexible deformities -Most flexible deformities from intrauterine positioning and usually resolve spontaneously -TX: -Flexible: No treatment -Rigid: Serial casting with cast changes every 1-2 weeks

Answer 5

-MC cause of limping and hip pain in children in the U.S. (3-10 years) -Self-limiting, acute inflammatory reaction often following an upper respiratory or GI infection -Hip joint experiences limited ROM, particularly internal rotation -Radiographic findings are nonspecific; some swelling apparent in soft tissues around joint -Must differentiate from septic arthritis! -No elevation in ESR, WBC count, or fever > 38.3C; clear aspirate from joint (if performed) -More definitively distinguished from septic arthritis with a dynamic contrast enhanced MRI -Tx: -Rest and NSAIDs -Radiographic follow-up important: May be precursor to AVN of femoral head (6 weeks or earlier if limp persists)

Answer 6

-Source varies according to age -Infantile: Adjacent osteomyelitis -Older kid: Isolated infection w/o bony involvement -Teens: Underlying systemic ds or organism that has affinity for joints (Neisseria gonorrhoeae) -MC organism varies by age -< 4mo: GBS, S. aureus -4mo–4yrs: H. influenza B (if unimmunized), S. aureus -Older kids/adolescents: S. pyogenes, S. aureus, S. pneumoniae, N. meningitidis, N. gonorrhoeae -Kingella kingae is a gram-neg bacterium increasingly recognized as cause in < 5yo -Initial effusion rapidly becomes purulent -> may affect adjacent bone -Infants: Decreased abduction of hip, irritable, or feeding poorly -Older kids: Fever, malaise, vomiting, restriction of motion, joint swelling, warmth, erythema, and/or tenderness -Imaging: -Plain radiograph: -Dislocation of joint (within days) -Destruction of joint space, resorption of epiphyseal cartilage, erosion of adjacent bone of metaphysis (later) -Bone scan: Increased flow and uptake about joint -MRI/US: Joint effusion detection

Answer 7

-Aspiration of joint for dx -Need for aspiration evaluated with Kocher criteria -NWB, ESR > 40 mm/h, temp > 38.5C, WBC > 12K cells/mm^3, CRP > 2.0 mg/dL -Surgical drainage with WBCs > 30-50K cells/mm^3 followed by appropriate antibiotic therapy -Empiric: Nafcillin, oxacillin + third generation cephalosporin -Antistaphylococcal agent alone usually adequate > 5 years (unless gonococcal/meningococcal infection suspected) -Prognosis: Excellent prognosis if joint drained before damage to articular cartilage (> 24 hours) and/or growth plates

Answer 8

-Oligoarticular (MC form, 40-60%): 4 or fewer joints, medium to large joints, asymmetrical (children may develop leg-length discrepancy) -20% develop !!asymptomatic uveitis (may cause blindness) -Polyarticular (20-35%): 5 or more joints, large and small joints, symmetrical -Low grade fever, fatigue, rheumatoid nodules, and anemia may be present -Further divided into !RF-positive versus RF-negative: Positive is more chronic, destructive arthritis -Systemic (10-15%): Any number of joints, large and small joints -High fever (39-40C), typically 1-2 times per day -~80-90% of patients have evanescent, salmon-pink macular rash! that is most prominent on pressure areas, especially when fever is present -Other systemic features: Hepatosplenomegaly, lymphadenopathy, leukocytosis, and serositis -Enthesitis-associated (5-10%): MC in males older than 10 years of age, typically, associated with lower extremity, large joints, hallmark is inflammation of tendinous insertions (enthesitis) -Low back pain and sacroiliitis also common -Psoriatic -May have typical psoriasis or more subtle changes, like nail pitting -May have dactylitis (“sausage digit!”) – painful swelling of entire finger or toe -Undifferentiated (10% of patients): Chronic arthritis without meeting criteria for any of the other subgroups or meet more than one criterion that classify them into multiple subgroups

Answer 9

-Labs: -No diagnostic test for JIA -Markers: -ANA associated with increased risk of uveitis in those with oligoarticular disease and those with late-onset, RF-positive form of disease -RF is positive in ~5% of patients (usually when polyarticular form occurs after 8 years of age) -Anti-CCP has high specificity for RA and may be elevated prior to RF -Systemic JIA: Significantly elevated markers of inflammation (ESR, CRP, WBCs, platelets) -HLAB27 antigen associated with increased risk of developing enthesitis form -Joint aspiration performed to rule out infection -JIA: 5K-60K WBCs/uL, glucose usually normal or slightly low -Imaging -Early disease: -Plain films: Soft tissue swelling, periarticular osteoporosis -MRI: Early joint damage; if with gadolinium, can confirm presence of synovitis -US: Synovitis, tenosynovitis, and bony erosions -Later disease: Plain films: Joint space narrowing, erosive changes of bone related to chronic inflammation

Answer 10

-Objectives are to restore function, relieve pain, maintain joint motion, and prevent damage to cartilage and bone -!!NSAIDs: Naproxen, ibuprofen, meloxicam -Symptomatic improvement after 1 month or up to 8-12 weeks -Disease-Modifying Agents: Methotrexate, leflunomide, JAK inhibitors -Weekly methotrexate: Response within 3-4 weeks, CBC and LFTs every 2-3 months -Biologic Agents (inhibit TNF): Etanercept, infliximab, adalimumab, rituximab, abatacept -Corticosteroids: -Local injections with triamcinolone acetonide -PO/parenteral for severe involvement/systemic disease -Uveitis: Corticosteroid drops and dilating agents to prevent scarring between iris and lens -Systemic medications for failure of topical treatments -Rehabilitation: -PT/OT to focus on ROM, stretching, and strengthening -Leg-length discrepancy: Shoe lift on shorter side -Prognosis: -Variable, based on subtype -Persistent oligoarticular have highest rate of clinical remission -RF-positive disease least likely to achieve remission and highest risk for chronic, erosive arthritis -Systemic disease worse in those with persistent symptoms past 6 months, thrombocytosis, and more extensive arthritis

final - ortho Flashcards

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